Co-Applicant:

List additional persons that will reside with you (including children):

If you will not have additional persons residing with you, just skip.

Name

FirstLast

Birthdate

MM

DD

YYYY

Gender

Male

Female

Relationship

Disabled

Yes

No

Name

FirstLast

Birthdate

MM

DD

YYYY

Gender

Male

Female

Relationship

Disabled

Yes

No

Name

FirstLast

Birthdate

MM

DD

YYYY

Gender

Male

Female

Relationship

Disabled

Yes

No

Eligibility Verification

Property Taxes Paid Current:*

Yes

No

Applicants' Name on Deed of Record (no land sales contracts):*

Yes

No

Applicant Currently Resides in Home:*

Yes

No

Please attach the following:

Provide the following income verification documents for ALL household members:
- 2012 tax return (signed and dated) with W-2’s and 1099’s attached
- 2013 award letters (Social Security, Supplemental Security Income (SSI))
- 3 months of recent paystubs
- Current documentation for all other forms of income including but not limited to: unemployment benefits, military income, public assistance (not including food stamps), child support payments (past 12 months), alimony, retirement funds, pensions, real estate property income, etc.
- Most recent 2 months bank statements
- Complete copy of your bankruptcy, if applicable
- EACH household member 18 and over must fill out and sign the attached “Income Certification Questionnaire” and “Authorization for Release of Information Form”
- Copy of Identification (current State ID or Drivers License for Applicant Only)
- Copy of Social Security Cards (for all household members)
- Homeownership verification
- Copy of the property deed and mortgage papers if applicable
- Death certificate if anyone on title is deceased
- Proof of paid property taxes
- Current utility bills (TWO of the following: water, electric, gas)
- Proof of homeowner’s insurance
You can also send these documents to info@kingpark.org.

File Upload

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Special Assessments (Lead Safety Qualifications)

Number of children 6 and under:*

Number of female occupants currently pregnant:*

If no children live in the home, are there children 6 and under who visit the home frequently?

grandchildren, nieces, nephews, etc.*

Yes

No

Has your home ever been tested for Lead Based Paint?*

Yes

No

General Dwelling Information

Year built:*

Approximate Square Footage?*

# of bedrooms:*

Is the home a double?*

Yes

No

Is the home a double?*

Yes

No

Is there a mortgage on the home?*

Yes

No

Is the home in foreclosure?*

Yes

No

Is your home in a designated Historic District?*

Yes

No

Repairs & Needs

Have you ever received services before from King Park?*

Yes

No

If yes, when?*

If yes, please describe:*

Has the property undergone any repairs or renovations in the last year?*

Disclosure/Privacy Statement

Services will be provided without discrimination because of age, race, color, religion, sexual orientation, gender, handicap, national origin or ancestry. This agency is requesting information necessary to comply with the requirements of this program. I understand that the information on this form will be kept confidential but may be shared with other agencies to which I may be referred for services. I understand that I may be requested to verify these statements, and give my consent to this agency to make necessary contacts to verify any statements. I hereby certify that the above information is correct and true to the best of my knowledge.
I, the homeowner, also acknowledge that the work requested may not all be performed and that the decision by King Park Area Development Corporation may be based on the availability of funds.

Homeowner Electronic Signature*

Please type in your name for the electronic signature. You may be required to provide a physical signature at a later date.

Date*

Co-homeowner Electronic Signature

Please type in your name for the electronic signature. You may be required to provide a physical signature at a later date.